Diabetes in Pregnancy

1. Diabetes in Pregnancy

2. Diabetes in Pregnancy • Introduction • Affects up to 3% of all pregnancies • 90% due to gestational diabetes • Perinatal mortality around 2-5%

3. Pathophysiology • Normal pregnancy: • glucose homeostasisis affected by increased estrogen, progesterone &HPL which lead to B cell hyperplasia and increased insulin secretion. Lower maternal fasting glucose levels. • Increased: glycogen deposition, fatty acids, triglycerides & ketones • Decreased: circulating amino acids • Maternal response is to increase protein catabolism and accelerate renal gluconeogenesis

4. Pathophysiology • Normal pregnancy: • lipids become an important fuel as pregnancy advances, fat storage increases. • With the rise of HPL, lipolysis is stimulated in adipose tissue. The release of glycerol and fatty acids reduces both maternal glucose and amino acid utilization and sparing them for the fetus • This action of HPL is responsible for the “diabetogenic state of pregnancy”along with increased cortisol. Estrogen and progesterone. • Fetal glucose level is similar to the mothers by facilitated diffusion, insulin dose not cross the placenta. Persistant elevated levels of glucose will stimulate the pancreas resulting in β-cell hyperplasia and fetal hyperinsulinemia

5. Maternal classification and risk assessment Modified white classification of pregnant diabetic women Gestational diabetes Pre-gestational diabetes

6. Effect of pre-existing diabetes on pregnancy • Pre-eclampsia and eclampsia • Diabetic ketoacidosis • Worsening pre-existing nephropathy • Worsening pre-existing retinopathy • Infection: genital > monilial • Polyhydramnios/ oligohydramnios • Cesarean delivery • Post partum hemorrhage • mortlaity

7. Fetal Morbidity and Mortality • 1-miscarriage • 2-teratogenecity , drug related • 3- Congenital Malformation • Caudal regression • Neural tube defect • CVS • 4- Macrosomia / IUGR • 5-Fetal Death

8. Diabetes Mellitus and Gestational DiabetesSummery of Management Options • 1- Pre-Pregnancy • Explain general risks and management of diabetes in pregnancy • Evaluate any additional risks with appropriate specialist referral (e.g. renal, ophthalmologic) • Optimize blood glucose control • Discuss effective contraception until good glucose control (avoid estrogen containing-preparations with vascular disease) • Folate supplementation(4-5 mg daily) for at least 2 months before or during first trimester

9. B- prenatal • 1- Detection of Diabetes in Pregnancy • 2- Treatment of the Insulin-Dependent Patient • 3- Fetal Surveillance • 4- Management of Gestational Diabetes

10. Pregnancy is diabetogenic • Occurrence of GDM • Unmasking latent DM • Worsening of existing DM • Shift of GTT upward • Need of more insulin in pregnancy • Need of less insulin after labour • High female to male ratio

11. Screening for DM • Now we screen all gravid women • At booking • At 28 weeks • High risk patients • Positive family history (mother, father, siblings) • Maternal obesity (BMI > 30 kg/m2, trunkal obesity) • Aged gravida • Poor obstetric history • Persistent glycosuria • Macrosomia • Hydramnios

12. Risk assessment • high risk patients should undergo glucose testing In the absence of this degree of hyperglycemia, evaluation for gestational diabetes mellitus in women with average or high-risk characteristics is by glucose tolerance test . A fasting plasma glucose level >125mg/dL or a casual plasma glucose >200 mg/dL meets the threshold for the diagnosis of diabetes

13. Methods of screening

14. Fasting and 2 hours postprandial venous plasma sugar during pregnancy. Fasting 2h postprandial Result <100 mg/dl < 145mg/ dl. Not diabetic >125 mg/ dl >200 mg/ dl. Diabetic 100-125 mg/dl 125-200 mg/dl. Border line indicates glucose tolerance test.

15. 50-g oral glucose challenge The screening test for GDM, a 50-g oral glucose challenge, may be performed in the fasting or fed state. Sensitivity is improved if the test is performed in the fasting state . A plasma value above one hour afteris commonly used as a threshold for performing a 3-hour OGTT. If initial screening is negative, repeat testing is performed at 24 to 28 weeks. 130 - 140 mg/dl

16. 3 hour Oral glucose tolerance test Prerequisites: - Normal diet for 3 days before the test. - No diuretics 10 days before. - At least 10 hours fast. - Test is done in the morning at rest. Giving 75 gm (100 gm by other authors) glucose in 250 ml water orally Criteria for glucose tolerance test: The maximum blood glucose values during pregnancy: - fasting 90 mg/ dl, - one hour 165 mg/dl, - 2 hours 145 mg/dl, - 3 hours 125 mg/dl. If any 2 or more of these values are elevated, the patient is considered to have an impaired glucose tolerance test.

17. Team care Obstetrician Dietitian Pysician The patient The patient is the most important member of the team by her compliance

18. Control of diabetes in pregnancy Exercise Diet Insulin

19. Antenatal care • Initial visit • Careful dating • White’s staging • Obstetric history • Funduscopy ** • Blood pressure • Urinalysis & culture ** • HbA1c ** • Regular visits • Tight glucose control • Pre-meal glucometery • Diet and insulin • Medical condition • Complications • Medical • Obstetric • Fetal assessment • Maturity • Wellbeing

20. 3- Fetal Surveillance Starting 32 week gestation, weekly • Ultrasound scan • CTG • Biophysical Profile

21. Diet control • What worsen diabetes • Infection • Lack of exercise • Drugs • Stress of life • Smoking • 25-35 kcal/kg ideal wt • 50% carbohydrate • 20% protein • 30% fat • Adjust for work • 3 meals and 3 snacks • Test for sugar before meals • Artificial sweeteners, high-fiber, low salt diet Your aim is not weight reduction, but proper glycemic control Proper weight gain is 1 Ib/mo in first half & 1 Ib/wk in second half

22. Advantage Exercising muscle utilizes glucose without insulin Synergistic with insulin Improves metabolic control Improve the mood and well-being Disadvantage Exercise-induced hypoglycemia Vigorous exercise worsen metabolic control precipitates lactic acidosis Strenuous exercise diverts blood to the muscles; it can cause IUGR Exercise for diabetics Regular exercise improves the outcome of pregnancy in diabetics but strenuous onedisproves it

23. Medical CVS diseases Retinopathy Nephropathy Obstetric PIH Over distended uterus History of premature labour Contraindication for exercise in pregnant diabetics

24. Insulin therapy • Human insulin (Actrapid, Initard 1/1, Mixatard 2/1) • Intermittent dosing • Twice daily doses (Lewis) • Before breakfast 2/3 dose (NPH: Regular 2:1) • Before dinner 1/3 dose (NPH: Regular is 1:1) • Thrice daily doses (Jovanovic) • Before breakfast 2/3 dose (NPH: Regular 2:1) • Before lunch 1/6 dose (Regular) • Before dinner 1/6 dose (NPH) • Continuous insulin infusion pump (CII pump) Daily dosage is calculated according to gestational age, severity of diabetes and actual body weight.

25. 2- Prenatal • Screen for gestational diabetes ideally in all pregnancies ( controversy over which test and whether just at 24-28 weeks): OGTT is diagnostic test • Regular capillary glucose series • Avoid oral hypoglycemic agent • Appropriate diet • Amend insulin regimen to keep capillary glucose values as normal as possible • Instruct partners/relatives in glucagon use for hypoglycemic attacks

26. 2- Prenatal • Baseline renal and possibly cardiac function • Randomized trials of low dose aspirin in women with vascular disease are awaited • Regular ophthalmologic review • Monitor for hypertensive disease • Fetal surveilance - Normality -Growth -Well-being(NST,BPS) -Umbilical artery blood flow • Gestational diabetics: initially try to control with diet rather than insulin; otherwise, as for established diabetics

27. Mode of delivery • Vaginal • Spontaneous or induced • Shoulder dystocia develops at lower birth weights • Caesarean section • Planned • Urgent • Neonatologist should be available

28. Delivery • Induction of labor at 38 weeks, as PNM starts to increase steadily afterward, for IDDM and GDM on treatment • If GDM on diet control with no complication allow till term • Timing of delivery depends on

29. Intrapartum care • Two infusion sets • G.I.K. 10% glucose + 10 I.U insulin + 10 mmol K • 1-2 hourly blood sugar check and infusion adjustment according to level • keep the blood sugar 90-120 mg/dl • CTG during labor & delivery

30. Post-partum care • Readjust the dose of insulin • Encourage breast feeding • Reassess the glycemic status • Give a suitable contraceptive • Weight reduction to delay NIDDM • Follow-up for NIDDM

31. Neonatal complications • Hypoglycemia • Respiratory Distress Syndrome • Hypocalcemia • Hypomagnesemia • Jaundice Requiring admission to nursery for monitoring and Rx